Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you manage active severe psoriasis in a patient planning pregnancy, who also has psoriatic arthritis with well-controlled joint symptoms on certolizumab pegol (anti-TNF therapy)?
If the psoriasis was sufficiently limited in area that topicals were a practical solution, I'd first try to assure that the prescribed topical steroids were being used well. Poor adherence is a common issue with topical treatment. Phototherapy might be my next choice. I feel comfortable prescribing ...
Would you initiate antifibrotic therapy in a patient with CTD-ILD experiencing worsening symptoms and declining lung function, despite no clear evidence of fibrosis on CT scans?
If the predominant findings on CT were ground glass opacities and/or nodules without any evidence of fibrosis on CT, I would not start with an antifibrotic and, instead, would start with immunosuppression as a first-line agent. Based on the American College of Rheumatology (ACR) and American Thoraci...
Under what circumstances would you hold an ACE inhibitor or ARB prior to surgery in a patient with CKD?
I suppose if it was a high risk for hypotension or fluid shift, I may hold it. I'd rather be a bit hypertensive than under-perfused. If they are being used for reno protection, getting off them for a short period will have no influence.
Where does dronedarone fall in your list of antiarrhythmics drugs to use in terms of efficacy and patient selection in contemporary management of atrial fibrillation?
Dronedarone tends to be my last choice for treatment of AF to maintain sinus rhythm of all currently available oral antiarrhythmic meds available in the US - least effective and very expensive drug. I may use it in patients that I believe would be better served with catheter ablation- treatment with...
What should the LDL target be in patients with prediabetes and high lipoprotein (a) with family history of coronary artery disease?
I don’t think that using Lp(a) to guide treatment is quite ready for prime time yet. It’s an independent predictor of risk compared to the rest of the lipid panel, but as far as I am aware, we do not yet have data that treating people based on it makes a difference. What I may do in this scenario is...
When home BP readings are consistently lower than office measurements, how do you decide whether to intensify, maintain, or de-escalate antihypertensive therapy?
If the home readings can be confirmed to be appropriately measured (i.e., in a hard-backed chair with arm support and checking multiple repeated readings), then I will adjust BP medications to target the average home BP of <130/80 (going lower toward 120/80, if tolerated). However, I have had patien...
What is your medication of choice when considering outpatient alcohol withdrawal management (diazepam vs chlordiazepoxide vs lorazepam)?
While benzodiazepines such as chlordiazepoxide, diazepam, and lorazepam remain the mainstay of treatment for acute alcohol withdrawal syndrome (AWS), their use in the outpatient setting is generally inappropriate for patients with Alcohol Use Disorder (AUD)—except in narrowly defined, low-risk scena...
What is your medication of choice when considering outpatient alcohol withdrawal management (diazepam vs chlordiazepoxide vs lorazepam)?
While benzodiazepines such as chlordiazepoxide, diazepam, and lorazepam remain the mainstay of treatment for acute alcohol withdrawal syndrome (AWS), their use in the outpatient setting is generally inappropriate for patients with Alcohol Use Disorder (AUD)—except in narrowly defined, low-risk scena...
Do all patients initiating omalizumab need to have it administered in a healthcare setting?
In the trials, all cases of anaphylaxis were on first administration--suggesting it is not intrinsic to drug and is more likely because you are giving it to a group of people who may be more susceptible to anaphylaxis in general. FDA has cleared at home use, so my general approach in a patient witho...
How do you approach the management of newly discovered prediabetes in adults over the age of 65?
We know that even at the same given HgA1c, a 90-year-old patient and a 30-year-old patient have different patterns in their day-to-day sugars. The 90-year-old patient will have a wider amplitude of sugars above and below a given average sugar level. Therefore, while a given HgA1c gives us an idea of...